Atul Gawande tells us healthcare needs a system that emphasizes simplicity.

Long Beach, California—Harvard's Atul Gawande says that the solution to our expensive (and growing) healthcare problems is simple. What we need, he told the TED audience, is a system—a real system that emphasizes the importance of simplicity. How could the complexities of our healthcare system possibly be handled by increased simplicity?

Gawande, who specializes in reducing risks in medical contexts, is in a position to appreciate the advantages of simplicity. A big challenge in medicine today starts at the doors of medical school. While we may be eager to blame governments or insurers, the cause of our health care troubles is the complexity that science has given us, which in turn dictates how we train our doctors. We end up with doctors that take on specializations, nurses that take on specializations, and drugs that are increasingly specialized as well.

This produces doctors that are trained to be cavalier and strongly individualist—cowboys of a sort. And thanks to movies and television, we idealize the arrogant cowboys, doctors who are capable of spotting the 1-in-1,000 exception to a standard diagnosis. But that, according to Gawande, is the wrong model to idealize. "We have trained, hired, and rewarded people to be cowboys," he said. "But it’s pit crews that we need."

Even as recently as the beginning of the 20th century, being in the hospital was an improvement for most people simply because it was a warm, safe place. The doctors and nurses were, to an extent, irrelevant. Their job was to try to find a diagnosis for which they could do something, but they didn't know much and therefore couldn't do much. And a great deal of what they did know did not have a scientific foundation.

Today, we not only have a massive catalog of scientific diagnoses, but we also have treatments for thousands of illness—Gawande cited estimates of 6,000 drugs and 4,000 surgical procedures. And we want to deploy these town by town, to every person in the US, and eventually to the whole world. Our current model for doing so puts healthcare professionals in the front, with doctors leading them, since they are supposed to be the masters of health care knowledge and practice.

But the complexity that science has given us is sprawling. In 1970, it took the time-equivalent of two healthcare professionals to care for someone in the hospital. In the last decade, that has grown to fifteen (doctors, nurses, therapists, etc.). Part of the reason is that everyone is a specialist now. We have trained, hired, and rewarded people to be medical cowboys, and, as a result, a patient has an impressive array of talent if they can afford it.

The problem is that this is not sustainable, and our gut response to solving it is misplaced. "If we believe that it’s only technology that handles the complexity, we will go adrift," Gawande argued.

What we need are really pit crews for patients. While we might idealize doctors and seek out specialists for everything, they're costly and not always available when we need them to be. The result is partial care. Forty percent of coronary patients receive incomplete care. Sixty percent of asthma patients have incomplete care. There are real consequences to this: consider that 2 million people come into the hospital and get a new infection because someone failed to follow the basic practices of hygiene.

Gawande went on to list other problems caused by specialization:

A lack of coordination: We have amazing clinicians paired with incredible technologies. But we don't bring these things together in the most optimal way. Doctors who could once wrangle together what was needed to provide care can no longer do so, because they don't necessarily know what's available outside their narrow specialization.

Mistaken priorities: The best care is not always the most expensive care, but we sometimes assume that it is, and in fact, this is the very model we have built with specialization. Having great, expensive components isn't enough—how it all comes together is far more important than individual pieces.

Consider taking the best automotive parts on the market and trying to make a car. A Porsche braking system, a Ferrari engine, a Volvo chassis. Put it all to get and what do you get? "A piece of junk that doesn't go anywhere… It's not a system," Gawande notes.

Having made the argument that the lack of coordination was (in some cases literally) killing us, Gawande suggested that the way forward will be to truly systematize care. To do that, we need to abandon the cowboy model of medicine, collectively discover where our failures are, devise solutions, and get them implemented.

This isn't glamorous work, but it is essential. Sometimes the solutions can be as simple as a checklist. A preflight checklist, for instance, doesn't tell the pilot how to fly, but it aides the pilot in avoiding common mistakes. And we already know these work for medicine, too; in some countries, checklists before surgery improved survival rates far greater than any single drug could.

The challenge will be convincing the cowboys to accept something like this. In his initial work, Gawande said it was possible to tailor even simple solutions to highly skilled professionals. "We asked Boeing to help us design a checklist for not the least skilled doctors, but the most skilled," he said.

But getting these solutions incorporated widely within the medical community will require a complete cultural change. We have to leave behind the days where autonomy and individualism were the traits our medicine was founded on. "Complexity requires group success," Gawande said. "We all need to be a pit crew now." Many aspects of our medical system will also need to change for this to happen, though, and at the moment, the incentives simply aren't in place to drive those changes.

66 Reader Comments

Atul Gawande is the name that came to mind when I saw the headline. His name is synonymous with Checklist in my office. Using his methodologies in this and previous jobs I've held, I've saved ridiculous amounts of money for myself and my companies that I've worked for.

Proper checklists are so simple and yet so mandatory to risk mitigation and time management that once you use them properly, you cannot understand how people think to function without them.

Atul Gawande is the name that came to mind when I saw the headline. His name is synonymous with Checklist in my office. Using his methodologies in this and previous jobs I've held, I've saved ridiculous amounts of money for myself and my companies that I've worked for.

Proper checklists are so simple and yet so mandatory to risk mitigation and time management that once you use them properly, you cannot understand how people think to function without them.

I'm sure checklists would produce measureable improvements in some areas (especially patient safety) but they're not going to fix the absurd cost of medical school, or various insurance company fuckery, or the complete unwillingness of the federal government to implement any sort of cost controls because that would be socialism, etc.

The challenge will be convincing the cowboys to accept something like this.

That is exactly right.

My fiance works in quality management at a large US hostpital in a major city. One of her job duties is to observe routine surgeries and follow a step-by-step checklist to grade the surgical staff on how well they follow procedure. It is astonishing to hear what steps are skipped. One of the most common is during C-sections-- the first thing the physician is supposed to do is to introduce themselves to the patient, ask the patient's name, and double-check the names on the wrist-tag and chart to make sure that they all match. This step is almost always skipped, even though there is literally a gigantic checklist on the wall of the delivery room with that step at the very top.

Hospital systems are generally pretty tolerant of single faults or oversights, but occasionally a few discrete issues line up and tragic outcomes occur due to numerous preventable mistakes.

To continue with the analogy, the pit crew would need a crew chief. The crew chief needs to have broad, not deep, knowledge, and at least the ability to lead the team through the checklists or whatever system is devised.

This is a very odd article. I am a nurse, working in burns, in a major research hospital. There are tons of checklists that I use very frequently - from core measures, procedural checklists, intervention checklists, and checklists dictated by policy or regulations. Tons of checklist.

On coordination of care - frankly, this isn't the doctors job. The health care field is setup like the military. Doctors are like the brass and nurses are like the enlisted schmucks. The doctors dictate care and the nurses implement it - except in the case of invasive procedures. Doctors are already spread thin enough - do you want them having to call everyone up to make sure orders are implemented, coordinating tests with patient care, etc?

In burns, we have a very integrated multi-disciplenary team: doctors, nurses, nursing assistants, unit secretaries, social workers, physical therapists, occupational therapists, recreational therapists, care management, etc. working with the patient - believe me this is expensive because so many people are working together.

We need specialization in care, I can tell you this from a personal perspective. I see plenty of patients coming in from outside hospitals and even our own emergency department with burns. In most cases (i.e., virtually all) the patient's burns are totally inadequately taken care of from top to bottom. I'm talking about misdiagnosis of total body surface area and depth/degree, inappropriate or non-existant fluid resuscitation, incorrect medicine applied including tetanus shots not being administered, incorrect wound dressing (trust me, dressing the wound the wrong way will cause it to be absolutely excruciating when it is removed), as well as an inability to determine whether the person should be admitted or not. And these mistakes are coming from highly-educated and experienced individuals! I've had these mistakes come from military ED doctors!

I do agree that the cowboy mentality needs to be kicked. This is really being tackled at my hospital's school of medicine where they have the MDs shadow RNs as part of their education to get a better perspective on how the totality of care is delivered.

Basically what I am saying is this: 1) this is a very simplistic view that would only help out the most inefficient hospitals, and 2) the cost savings from these suggestions have already been achieved in most cases.

That's actually a really tough one. There is a definite advantage to having Type-A independent cocky badasses as surgeons; they are in charge, they are the experts, and they need to have no shame in acting that way. It's a really fine balance between allowing doctors to take charge and make on-the-spot decisions and having everything boiled down to a step-by-step manual in a 3-ring binder in the corner that has to be followed perfectly.

On coordination of care - frankly, this isn't the doctors job. The health care field is setup like the military. Doctors are like the brass and nurses are like the enlisted schmucks. The doctors dictate care and the nurses implement it - except in the case of invasive procedures. Doctors are already spread thin enough - do you want them having to call everyone up to make sure orders are implemented, coordinating tests with patient care, etc?

Uh, yes, that is exactly the doctor's job, and I certainly want MY doctor to be making sure that everything they ordered happened and coordinating my care. The fact that this is NOT the expectation is a major problem.

That's actually a really tough one. There is a definite advantage to having Type-A independent cocky badasses as surgeons; they are in charge, they are the experts, and they need to have no shame in acting that way. It's a really fine balance between allowing doctors to take charge and make on-the-spot decisions and having everything boiled down to a step-by-step manual in a 3-ring binder in the corner that has to be followed perfectly.

I woke with surgeons and I have seen this attitude cost someone their life. We have a saying in this field, you bury your mistakes. You don't make a mistake, you don't make a body. You can _feel_ it's an advantage to be a type-A independent cockey badass operating on you - just pray to FSM that nothing bad happens because that very same attitude can and does prevent the surgeon from asking for help.

There is a huge realm of difference between being a cowboy and having all of your actions dictated in advance. When a surgeons consults another doctor because the pt has a post-op infection, they can save a life. When they double-down and say they did everything right, that can cost a life.

On coordination of care - frankly, this isn't the doctors job. The health care field is setup like the military. Doctors are like the brass and nurses are like the enlisted schmucks. The doctors dictate care and the nurses implement it - except in the case of invasive procedures. Doctors are already spread thin enough - do you want them having to call everyone up to make sure orders are implemented, coordinating tests with patient care, etc?

Uh, yes, that is exactly the doctor's job, and I certainly want MY doctor to be making sure that everything they ordered happened and coordinating my care. The fact that this is NOT the expectation is a major problem.

Doctors don't coordinate care in hospitals, nurses do. The hospital I work at has 36 burn beds, 2 ORs, and a burn clinic for followup and outpatient care, as well as administrative and teaching duties - for 3 doctors. Do you think a doctor has time to keep following up on every patient's radiology tests, lab work, vitals, input/output, various therapy regimens, scheduling of drug administration, wound care, etc, etc, etc?

I get 5 patients and my job is to coordinate the care of the patient - that is in fact the whole purpose of a hospital - to get 24hr nursing care. Otherwise you can go to a doctors office, ambulatory care surgery, or urgent care where doctors do a lot more micromanagement. That is appropriate for some areas of care delivery, but not for hospitals.

One of the biggest frustrations I have is doctors who refuse to communicate with one another. Specialists and general practitioners are often trampling on each others treatments, often in counterproductive ways.

Just last week I had my primary care physician prescribe me a drug that would have severely exacerbated the long-term chronic condition I've been dealing with. The only reason I caught it is because I look up every drug I was prescribed, and the contraindications and side-effects sounded like something that someone with my condition should avoid. Sure enough I contacted my specialist who agreed and told me I absolutely should not be taking that drug.

What makes this all the worse is that I made a point to keep all of my physicians within the same health system, one that utilizes electronic records. All of my doctors can see all of the tests and records performed by my other doctors, and they still seem to be clueless of what they're doing.

To extend Gawande's analogy, you need a pit crew and a crew chief to keep the driver moving. You still need the driver, who's a specialist in making the car get from A to B (to A to B, ad nauseum) quickly. You need a crew chief to get info from the driver and disburse it to the crew. You need crew specialists to take the information and correctly determine a fix.

This is rather like tech support; we have a lot of checklists. Not necessarily for every specific problem or action, but we have a basic checklist (What's your name? What's the symptom? Have you don't anything do it recently? Here's your case number.) that happens every time. We have a checklist to determine how to hand off problems, to make sure higher tiers get the information they need. We have checklists for verifying the problem is resolved and terminating the service incident (Client plugged USB keyboard into ethernet port. Moved keyboard plug to compatible port.). I can see how the medical industry would benefit from such a thing.

For instance, you go to your GP and he's got a mandated checklist that makes sure that you are, in fact, you (so he doesn't accidently send you in for a vasectomy), has a spot for basic symptoms, and a spot for resolution (which may be "Heart is leaking, sent to coronary specialist"). It's got instructions for making sure everyone--client, GP, and if applicable specialist--is on the same page. There's probably something in there about estimates and insurance forms, making sure clients are suddenly blindsided by 20,000 charges they thought the insurance was covering.

This doesn't demote any of the components of the process, though, it just makes sure that there's a universal process to help avoid mistakes and miscommunications. We still have cowboys, after all, we just make sure they're wearing steel-toed boots and not feeding heroin to the cattle.

I get where he is coming from. I grew up in a smallish town with a dozen or so doctors for 10,000 people, one hospital, and only two surgeons, both of whom were also GPs.

Growing up you went to see your GP, and he did his thing, maybe he sent you for a blood test at the hospital, but mostly you saw him and one of his staff. But as I get older, I'm in my 30s now, those GPs have retired and now when I go to a Doctor I get refereed all over the place.

"Got a sore knee? Go to this specialist!" "got a headache? neurologist!"

General Practitioners are a dying breed, and it's going to be very bad thing for the health care system.

Oh and by the way, that car analogy is horrible. All cars are a combination of parts from different manufacturers. And many of those parts fit perfectly well on other cars too.

Really? So, the drive-train from a Suburban would fit perfectly well in an Escort? And the wheels/tires on a Volt will work just fine on an Escalade? And you can fit the motor from a Mack truck into a Silverado or Tundra? Message me and let me know how that works out.

Hospitals use checklists. Its a fact - I use them everyday. There are a variety of checklists for a variety of tasks.

Any cost savings that could be achieved from using checklists are already achieved because of the use of said checklists. And that savings is obviously a miniscule amount because health care is still really, really expensive. We would save a lot more money by dealing with medical device and pharmaceutical costs, as well as taking profit out of the system.

In burns, we have a very integrated mulch-disciplenary team: doctors, nurses, nursing assistants, unit secretaries, social workers, physical therapists, occupational therapists, recreational therapists, care management, etc. working with the patient - believe me this is expensive because so many people are working together.

And you do not see the problem with all these people involved in ONE patients care, then go on later to complain how you see misdiagnosis and other issues. You think this may be caused because there are exactly to many people involved, and they are relying on someone else to do a job that they should have done? And we wonder why health care is so expensive.

While checklists might improve our quality of care and might reduce the costs of care, the fallacy in this article lies in this bald assertion:

> While we may be eager to blame governments or insurers, the cause of our health care troubles is the complexity that science has given us, which in turn dictates how we train our doctors.

This is, in a word, bunk. Pretty much every analysis of our current "health care troubles" -- and, the only "troubles" we're having is our spiraling-out-of-control costs -- has concluded that it is our insurance and payment scheme that is to blame, not bad or incomplete medicine.

So, no -- "fixing" healthcare could NOT be as simple as a checklist. It would certainly make things better, but ultimately to fix it you have to attack the core profit drivers in the industry, and THAT isn't going to happen just because some smart guy has a brainstorm.

In burns, we have a very integrated mulch-disciplenary team: doctors, nurses, nursing assistants, unit secretaries, social workers, physical therapists, occupational therapists, recreational therapists, care management, etc. working with the patient - believe me this is expensive because so many people are working together.

And you do not see the problem with all these people involved in ONE patients care, then go on later to complain how you see misdiagnosis and other issues. You think this may be caused because there are exactly to many people involved, and they are relying on someone else to do a job that they should have done? And we wonder why health care is so expensive.

Hospitals use checklists. Its a fact - I use them everyday. There are a variety of checklists for a variety of tasks.

Any cost savings that could be achieved from using checklists are already achieved because of the use of said checklists. And that savings is obviously a miniscule amount because health care is still really, really expensive. We would save a lot more money by dealing with medical device and pharmaceutical costs, as well as taking profit out of the system.

No, they don't. Not all of them. Not even close. Stop confusing YOUR hospital with ALL hospitals.

This is a very odd article. I am a nurse, working in burns, in a major research hospital. There are tons of checklists that I use very frequently - from core measures, procedural checklists, intervention checklists, and checklists dictated by policy or regulations. Tons of checklist.

On coordination of care - frankly, this isn't the doctors job. The health care field is setup like the military. Doctors are like the brass and nurses are like the enlisted schmucks. The doctors dictate care and the nurses implement it - except in the case of invasive procedures. Doctors are already spread thin enough - do you want them having to call everyone up to make sure orders are implemented, coordinating tests with patient care, etc?

In burns, we have a very integrated multi-disciplenary team: doctors, nurses, nursing assistants, unit secretaries, social workers, physical therapists, occupational therapists, recreational therapists, care management, etc. working with the patient - believe me this is expensive because so many people are working together.

We need specialization in care, I can tell you this from a personal perspective. I see plenty of patients coming in from outside hospitals and even our own emergency department with burns. In most cases (i.e., virtually all) the patient's burns are totally inadequately taken care of from top to bottom. I'm talking about misdiagnosis of total body surface area and depth/degree, inappropriate or non-existant fluid resuscitation, incorrect medicine applied including tetanus shots not being administered, incorrect wound dressing (trust me, dressing the wound the wrong way will cause it to be absolutely excruciating when it is removed), as well as an inability to determine whether the person should be admitted or not. And these mistakes are coming from highly-educated and experienced individuals! I've had these mistakes come from military ED doctors!

I do agree that the cowboy mentality needs to be kicked. This is really being tackled at my hospital's school of medicine where they have the MDs shadow RNs as part of their education to get a better perspective on how the totality of care is delivered.

Basically what I am saying is this: 1) this is a very simplistic view that would only help out the most inefficient hospitals, and 2) the cost savings from these suggestions have already been achieved in most cases.

You should read Gawande's book. It's just as much about poorly made checklists and other such reminders causing problems as it is about good ones making huge positive impacts. The most counter intuitive lesson from the book is actually how difficult it is to make good checklists. I have to agree with the fanboy first post. The Checklist Manifesto should be required reading for anyone who works in a field where human error can lead to death, morbidity, or significant financial losses. It is required at the medical school I work for.

The biggest problem that no one seems to be mentioning, is that specialization equals more money for the specialist. Good luck getting doctors to become a member of a pit crew, when they know that means a pay cut.

Do you think a doctor has time to keep following up on every patient's radiology tests, lab work, vitals, input/output, various therapy regimens, scheduling of drug administration, wound care, etc, etc, etc?

Frankly, yes, as that is his/her job, to follow up to make sure everything was done. I see a specialist every 6 months and he is affiliated with a hospital with over 1,300 doctors, yet he personally follows up on each of his patients care. Maybe because it is where he was born and trained (Latin America) as to why he takes a personal interest in each patient. He does not have that cavalier "it is not my job, let someone else do it" attitude that you exude. I would rather be treated by him at his large hospital and receive personal attention, than at your small hospital and have 15 people attending to me, and not know what is being done and by who, when, and why. That is how mistakes happen, with "to many chefs in the kitchen."

We would save a lot more money by dealing with medical device and pharmaceutical costs, as well as taking profit out of the system.

Indeed. I think it's also perverse that healthcare is (in some countries) an industry for profit. I'd much prefer it if the people taking care of me are only concerned with my well-being, and not with how to make money out of my condition.

On coordination of care - frankly, this isn't the doctors job. The health care field is setup like the military. Doctors are like the brass and nurses are like the enlisted schmucks. The doctors dictate care and the nurses implement it - except in the case of invasive procedures. Doctors are already spread thin enough - do you want them having to call everyone up to make sure orders are implemented, coordinating tests with patient care, etc?

Uh, yes, that is exactly the doctor's job, and I certainly want MY doctor to be making sure that everything they ordered happened and coordinating my care. The fact that this is NOT the expectation is a major problem.

Doctors don't coordinate care in hospitals, nurses do. The hospital I work at has 36 burn beds, 2 ORs, and a burn clinic for followup and outpatient care, as well as administrative and teaching duties - for 3 doctors. Do you think a doctor has time to keep following up on every patient's radiology tests, lab work, vitals, input/output, various therapy regimens, scheduling of drug administration, wound care, etc, etc, etc?

I get 5 patients and my job is to coordinate the care of the patient - that is in fact the whole purpose of a hospital - to get 24hr nursing care. Otherwise you can go to a doctors office, ambulatory care surgery, or urgent care where doctors do a lot more micromanagement. That is appropriate for some areas of care delivery, but not for hospitals.

While checklists might improve our quality of care and might reduce the costs of care, the fallacy in this article lies in this bald assertion:

> While we may be eager to blame governments or insurers, the cause of our health care troubles is the complexity that science has given us, which in turn dictates how we train our doctors.

This is, in a word, bunk. Pretty much every analysis of our current "health care troubles" -- and, the only "troubles" we're having is our spiraling-out-of-control costs -- has concluded that it is our insurance and payment scheme that is to blame, not bad or incomplete medicine.

So, no -- "fixing" healthcare could NOT be as simple as a checklist. It would certainly make things better, but ultimately to fix it you have to attack the core profit drivers in the industry, and THAT isn't going to happen just because some smart guy has a brainstorm.

Well yes and no. There are two different issues here. One is the COST of healthcare and one is WASTE in the healthcare system. Even if we eliminated waste, the cost would still be increasing because as medical science advances, we can treat more people that we used to. A lot of people who undergo expensive and complex treatments would have died 60 years ago. Letting people die is usually cheaper than giving them complex treatment by specialists. When lack of medical sophistication forced more people into the "we can't do anything to fix this" camp, healthcare was cheaper. Insurance companies certainly contribute to waste, but costs would have increased anyway. When the genie is let out of the bottle on any particular treatment, obviously nobody wants to go back. You can't say "well we used to have no choice but to let people with this condition go untreated, now we DO have a choice but it's too expensive so we'll just not provide that treatment and people shouldn't really mind because no treatment is what they are already getting." It doesn't work like that and people won't tolerate effective treatments going unused due to cost, science creates more treatment options, therefore science creates more costs.

Gawande's main point which the sentence you point out doesn't really touch on well is that the hospitals which provide the best care are also the hospitals which provide the cheapest care. You'd think it would be the other way around, but errors cost so much money that the cost of running a top in the world clinic is usually less than running a worse one. When the treatment for lower back pain was bed rest, you couldn't really mess that up. Medicine is more complicated now, errors hurt more than they used to because of it, and happen more than they used to because of it. Insurance companies aren't the only dragon which needs slaying.

While checklists might improve our quality of care and might reduce the costs of care, the fallacy in this article lies in this bald assertion:

> While we may be eager to blame governments or insurers, the cause of our health care troubles is the complexity that science has given us, which in turn dictates how we train our doctors.

This is, in a word, bunk. Pretty much every analysis of our current "health care troubles" -- and, the only "troubles" we're having is our spiraling-out-of-control costs -- has concluded that it is our insurance and payment scheme that is to blame, not bad or incomplete medicine.

So, no -- "fixing" healthcare could NOT be as simple as a checklist. It would certainly make things better, but ultimately to fix it you have to attack the core profit drivers in the industry, and THAT isn't going to happen just because some smart guy has a brainstorm.

This is true, but what Gawande was talking about actually integrates well with these ideas.

Look, I'm a physician who actually works in the exact field that Gawande is talking about, Quality and Safety improvement. I think his message is being drowned out by his emphasis on checklists. SOME things checklists help quite a bit (surgical procedures specifically), largely systematized processes that are pretty repeatable. However his true message is that Medicine has to start working like a truly safety and quality oriented organization, and not like it currently does with multiple little fiefdoms that barely communicate. This means we need to analyze the cost and payment structures (including reimbursement systems, and medication costs) currently used, to reduce waste and graft. This means we have to analyze our systems of care to reduce the risks involved.

Take, for example the ER. Waiting to be seen in the ER is a tremendously risky time. If a very ill person waits too long, their condition may turn drastically for the worse. Improving the quality of care means looking at how the ER works, and trying to figure out why it takes so long for a patient to get seen, and then redesigning the process to reduce that time, thus reducing risk.

This also means not being as gung ho about "new developments" just because they're new and shiny (and expensive). Many "improved" drugs, or therapies, are often crazy cost inefficient for the benefit they offer. Being relatively untested, they also can be VERY dangerous in often unforseen ways. In order to control costs the leaders of the Medical establishment (most often the government) have to be given more authority to slow or even stop the adoption of these things, especially if the observed benefit is not comparable to the price.

I use as an example of these costly and largely useless interventions the recent use of "metal on metal" hip replacements. A therapy that was new (and thus very expensive) and not really seen to offer a great deal of benefit. Yet because it was new (and they got a healthy reimbursement for it, as well as significant advertising by the medical device makers), Orthopedic surgeons used them in abundance. Now we find that what "metal on metal" really brings to the table is metal particles being shaved off into a joint, causing pain, debilitation, and need for repeated surgery in a not insignificant number of patients.

See also medications like Sorafenib, a massively expensive drug (cost, >4000$ per month), which was developed for use in end-stage liver cancer patients. It extends life by an average of 6 months, usually in a patient too debilitated to function in any significant capacity. It is useful in some patients, but its societal cost may be prohibitive. Think of how much 4000$ per month would do if it were used to pay for in terms of preventative care. This gets even more concerning when you realize that because of certain bargaining restrictions placed by members of Congress (Republicans mostly), insurers like Medicare CANNOT bargain with Pharma companies to bring down to price to a more reasonable level.

And yes, doctors are not without culpability. Too long have we worked in our little bubbles, poorly communicating, not caring about other aspects of medical care such as social work coordination, and coordination of care. Ignoring "inconveniences" like checklists because we think we know better. Doctors are also poorly trained to be team members, to work alongside instead of in opposition to nursing staff or other care providers. This is changing, though slowly.

This is going to be a long road, it's going to piss off alot of people, changing whole industries. But ultimately America needs a better, cheaper, more effective, more equitable, and less wasteful medical system than the one it has today. The current system is doomed to fail. We spend almost a quarter of our GDP, both publicly and privately on healthcare. This is increasing. In public healthcare costs ALONE we spend more than twice that of the next most expensive country (Canada). Despite this we don't have universal health care, in fact what we do have is a growing number of uninsured, uninsurable, and underinsured people. We also have worsening health statistics. In every measurable way our health care system is failing. Hopefully we can change as a society enough so that it doesn't completely give out on us, and we can build a workable system.

While checklists might improve our quality of care and might reduce the costs of care, the fallacy in this article lies in this bald assertion:

> While we may be eager to blame governments or insurers, the cause of our health care troubles is the complexity that science has given us, which in turn dictates how we train our doctors.

This is, in a word, bunk. Pretty much every analysis of our current "health care troubles" -- and, the only "troubles" we're having is our spiraling-out-of-control costs -- has concluded that it is our insurance and payment scheme that is to blame, not bad or incomplete medicine.

So, no -- "fixing" healthcare could NOT be as simple as a checklist. It would certainly make things better, but ultimately to fix it you have to attack the core profit drivers in the industry, and THAT isn't going to happen just because some smart guy has a brainstorm.

I want some research on this! (Disclaimer, I work for a health insurance company) Insurance is what everyone deals with and it's an easy target. As far as I know there has been no research published around cost breakdowns in health care. It's much the same trash as what the ***AAs spout about piracy.

What I do know is that I've had multiple doctors complain to me about what the insurance pays them for a visit onece they find out who I work for. That would be insurance driving the cost down. I know that the average profit margin for a health insurance company in the US is 3% while for a pharmacutical company it's 24%. In fact Obama Care mandates that 85 cents out of every dollar paid in insurance premiums goes to paying claims. That leaves 15% for total operating and administrative costs plus profit which tells me that that 3% number is accurate. The company I work for isn't even worried about that 85% thing as we're already meeting it. (We're the 3rd largest in the country so it isn't a mom & pop operation).

tl;dr: Do some research before assuming that your govenment is on the level when they pick a scapegoat.

Hospitals use checklists. Its a fact - I use them everyday. There are a variety of checklists for a variety of tasks.

Any cost savings that could be achieved from using checklists are already achieved because of the use of said checklists. And that savings is obviously a miniscule amount because health care is still really, really expensive. We would save a lot more money by dealing with medical device and pharmaceutical costs, as well as taking profit out of the system.

No, they don't. Not all of them. Not even close. Stop confusing YOUR hospital with ALL hospitals.

Many of these check lists are mandated by the government through CMS. I've worked at four hospitals in two states and I have had the exact same checklists in each state.

Does this guy actually practice medicine and work daily in the hospital field? In my experience, we've had a lot of these "external consultants" come in, say oh this is cake, just these 3 small things and your system is completely fixed. Its mostly a bunch of crap. Some things are simple but most of them are not. Its easy for people who don't have to deal with all the possible results to come in, observe 2-3 things and say it can be solved that easily.

They instead just collect their money and run merrily away while leaving the people working there to actually pick up after their mess.

Ken Fisher / Ken is the founder & Editor-in-Chief of Ars Technica. A veteran of the IT industry and a scholar of antiquity, Ken studies the emergence of intellectual property regimes and their effects on culture and innovation.